Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain

Abstract Aim Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. Design Observational cross‐sectional study. Methods Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. Results Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first‐degree tears and 273 (89.5%) always sutured second‐degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69–15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39–9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46–8.79) were significantly more likely to adopt a restrictive use of episiotomy. Conclusions There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. Patient or Public Contribution No patient or public contribution.

In response to the significant issues associated with perineal trauma post-childbirth, various interventions have been implemented for prevention and minimization (Aasheim et al., 2017;Fretheim et al., 2013;Kopas, 2014;Marcos-Rodríguez et al., 2023;Martínez et al., 2021).Notably, the avoidance of routine episiotomy is strongly advocated in most guidelines (World Health Organization, 2018), as restrictive episiotomy practices have not been linked to foetal acidosis or adverse infant outcomes (FIGO Safe Motherhood and Newborn Health (SMNH) Committee, 2012; Friedman et al., 2015;Hidalgo-Lopezosa et al., 2016).Consequently, the prevalence of routine episiotomy has been decreasing, though its use and overuse persist in many hospitals and among various midwives (Escuriet et al., 2015).
In light of this evidence, numerous scientific societies and agencies have developed clinical practice guidelines (CPGs) and protocols to standardize recommendations on perineal trauma prevention and episiotomy practice.In 2018, the World Health Organization Diverse strategies have been developed internationally aimed at mitigating severe perineal trauma, yielding outcomes with significant promise.These strategies encompass the initiation of interdisciplinary educational modules intended to bolster the confidence of midwifery practitioners in refraining from episiotomy procedures (Frost et al., 2016), eschewing the semi-reclined birthing posture in favour of training in controlled expulsive efforts and facilitating the spontaneous delivery of the shoulders (Basu et al., 2016), along with the application of prenatal perineal massage, manual safeguarding and the utilization of EPISCISSORS-60 to ascertain the precise episiotomical angle (Mohiudin et al., 2018).
Particularly, the research conducted by Borrman et al. (2020) merits attention, wherein a diminution in the incidence of severe perineal trauma was observed subsequent to the application of several aforementioned interventions, with sustained efficacy observed over a 2-year period.
Despite the established recommendations and the success of certain strategies in reducing perineal trauma, the preliminary step prior to identifying the most suitable strategies for implementation in our context involves understanding the current state of these practices within our environment.Investigating this topic could offer valuable insights for current clinical practice and underscore areas necessitating enhancement in professional training.This could considerably improve adherence to evidence-based recommendations.
Thus, the objective of this study was to assess the care practices of Spanish midwives in preventing and repairing perineal trauma, as well as to identify professional profile factors associated with the restrictive practice of episiotomy.

| Design
This study was a cross-sectional observational analysis focused on midwives practicing in Spain during 2021.

| Sample and settings
The estimated sample size was based on a reference population of 9593 active midwives (Instituto Nacional de Estadística, INEbase, 2020), assuming a 50% prevalence of the factor investigated (adopted due to the multi-response nature of the questionnaire and as a conservative estimate), an absolute error of 6%, a 10% replacement rate and a 95% confidence level.This calculation yielded a minimum required sample of 289 midwives.

| Measures
The study employed a self-developed, anonymous questionnaire comprising 27 closed questions: three on sociodemographic data, six on professional activity and work environment and 18 on techniques for perineal protection and repair during the second stage of labour.
• Employment-related variables: year of midwifery training completion, employment in public/private centres, involvement in home births, work in primary care, annual birth rate at their hospital and whether their institution trains obstetric professionals.
As dependent variables, the study inquired about various methods of perineal protection and repair.This included questions on suturing techniques, the application of warm compresses, intrapartum perineal massage, active perineal protection, manual control of head deflection, episiotomy procedures and techniques for suturing different types of tears.
The midwives were also presented with a figure showing different incision angles to be usually adopted for episiotomy and asked to choose the one used in their own practice (Figure 1).The primary dependent variable was the practice of restrictive episiotomy (defined as a rate under 10%), following the criteria of Blanc-Petitjean et al. (2020) and WHO targets (Technical Working Group, 1997).

| Data collection
The questionnaire was disseminated via email through various professional and scientific midwifery organizations, including the Federation of Spanish Midwives Associations (FAME) and the National Association of Midwives of Spain, alongside regional associations.
Midwives received an information sheet about the study and instructions for completing the questionnaire.A contact email was provided for any queries.

| Ethical considerations
This study was approved by the Clinical Research Ethics Committee (CEIC) of Hospital Mancha-Centro with protocol number 194-C.

| Statistical analysis
The analysis involved calculating absolute and relative frequencies for categorical variables and mean with standard deviation for quantitative variables.This was followed by bivariate and multivariate analyses, with the restrictive episiotomy practice as the main dependent variable and professional profile characteristics as independent variables.Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated (Chen et al., 2010).All analyses were conducted using SPSS 28.0.

| Practices related to the prevention of perineal trauma
Intrapartum perineal massage was not applied by 253 (83%) of midwives.Warm water compresses were used by 186 (61%), and 155 (50.9%) utilized lubricants to reduce the risk of tearing (Figure 2).

Active hand protection of the perineum was a common practice by F I G U R E 1 Commonly used incision angles.
254 (83.2%) (Figure 3), as was controlling the speed of head deflection by 273 (89.5%).Encouraging the woman not to push during head deflection was advised by 260 (85.3%) midwives.Regarding active shoulder traction, 169 (55.5%) did so rarely or occasionally, while 95 (31.1%) frequently employed this technique (Figure 4).The variability in these practices is detailed in Table 2.

| Variables associated with the use of restrictive episiotomy (<10%)
The multivariate analysis revealed several professional characteristics associated with the use of restrictive episiotomy.Professionals attending home births were more likely to employ this practice (aOR 6.50; 95% CI: 2.69-15.69)compared to those who did not.Similarly, professionals in hospitals with resident training (aOR 3.69; 95% CI: 1.39-9.84)and those trained post-2015 (aOR 3.58; 95% CI: 1.46-8.79)also showed a higher tendency towards restrictive episiotomy.
No significant relationship was observed between the professional's gender or the number of births attended and the use of restrictive episiotomy (Table 4).

| Prevention of perineal trauma
Within the purview of midwifery practice, essential interventions aimed at mitigating perineal trauma during the second stage of labour, that have been integrated into certain institutional protocols, encompass the application of compresses saturated with warm water, the active safeguarding of the perineum, and the regulation of the velocity at which the foetal head undergoes deflection (Borrman et al., 2020).Among these practices, the use the rate of head deflection with the other one, versus adopting expectant management in which the hands do not touch the perineum or the head.A Cochrane review found that expectant management reduces the rate of episiotomies but does not affect the rates of intact perineum or perineal tears (Aasheim et al., 2017).In 2015, a Systematic review of the literature concluded that both techniques are acceptable in childbirth care (Bulchandani et al., 2015).A metaanalysis on Ritgen manoeuvre (control of foetal head deflection) was published in 2019, which concluded that it is a technique that does not protect against perineal injury and may be associated with increased postpartum pain (Aquino et al., 2020) the application of lubricants and the facilitation of active shoulder birth, there was notable variability among midwives.This variation could be attributed to the lack of conclusive evidence regarding their effectiveness in tear prevention.

| Episiotomy
In our study, the majority of midwives reported episiotomy rates between 0% and 19.9% for eutocic births.However, a notable percentage reported rates between 20% and 39.9%.This aligns with a 2014 Spanish study, which found an average episiotomy rate of 34.9% among midwives (Hernández- Martínez et al., 2014).These figures are lower than those estimated in developing countries, where they can exceed 40% (Woldegeorgis et al., 2022).However, they surpass the rates reported in Western countries, which are documented at 19% (Goueslard et al., 2018), 10% (Leclercq et al., 2024), and even as low as 2% (Dillon et al., 2021).Despite these variations, a decreasing is observed, particularly in environments where midwives exercise greater clinical autonomy.
This trend is exemplified by the outcomes in a centre exclusively managed by midwives, which has reported a significant reduction in episiotomy rates to 7.4%, compared to those in traditional obstetric units (Palau-Costafreda et al., 2023).
A Cochrane review involving 12 studies with 6177 women compared restrictive versus systematic episiotomy, finding that restrictive episiotomy is associated with lower rates of severe perineal trauma and no correlation with low Apgar scores (Jiang et al., 2017).Gynécologues et Obstétriciens Français, identify the preservation of a woman's pelvic floor as a primary rationale for performing an episiotomy.This concern underscores the significance of the procedure in safeguarding maternal health.In our study, midwives were asked whether they would routinely perform episiotomy on pregnant women who had had severe tears (III or IV) in previous births in order to protect their pelvic floor, and most of them answered no.The available evidence currently considers that this practice does not prevent the occurrence of grade III or IV tears (Hernández- Martínez et al., 2014) and some CPGs such as the NICE guidelines Note: Method for interpreting the size of the OR by relating it to differences in a normal standard deviate.OR = 1.68, 3.47 and 6.71 are equivalent to Cohen's d = 0.2 (small), 0.5 (medium) and 0.8 (large) (Chen et al., 2010).* is multivariate analysis.Statistically significant values are bolded.

TA B L E 4
Restrictive episiotomy and its relationship with professional and work environment characteristics.
do not recommend its use for this purpose (National Institute for Health and Care Excellence, 2014b).
Furthermore, regarding the angle of incision, studies have demonstrated that midline episiotomies carry a higher risk of anal sphincter injury compared to mediolateral episiotomy (Pergialiotis et al., 2014(Pergialiotis et al., , 2020;;Verghese et al., 2016).Consequently, the use of midline episiotomy is discouraged (Okeahialam et al., 2023).Our study found that no midwives reported using midline episiotomy, aligning with the current recommendations.However, there was considerable variation observed in the implementation of different mediolateral angles.The optimal incision angle is debated, with some studies advocating for a 60° angle (Kalis et al., 2011), while NICE guidelines suggest an angle between 45° and 60° (National Institute for Health and Care Excellence, 2014b).The results obtained from our study show that only half of the midwives perform mediolateral episiotomy at an angle of 60°.

| Perineal repair
In our study, we explored midwives' practices regarding suturing these tears.While there was no consensus on suturing first-degree tears, the majority regularly sutured second-degree tears.Our literature review included a Randomized Controlled Trial (RCT) by (Fleming et al., 2003) which compared the outcomes of suturing versus not suturing first-and second-degree perineal tears.The study found that not suturing was associated with poorer healing and inferior tissue approximation.
Furthermore, the optimal method for repairing perineal injuries has been a subject of study.A 2019 clinical trial involving 134 women across five hospitals investigated the relationship between postpartum morbidity and the suturing technique used for perineal injuries.
The results indicated that continuous suturing was associated with less pain 3 months postpartum and lower rates of urinary incontinence 15 days postpartum (Martínez-Galiano et al., 2019).Additionally, a 2020 study comparing postpartum sexual function in women who received continuous versus interrupted sutures reported that those with continuous sutures experienced earlier and more satisfactory resumption of sexual activity (Martínez-Galiano et al., 2020).Consistent with these findings, most midwives in our study expressed a preference for continuous suturing over interrupted suturing techniques.

| Factors influencing the adoption of restrictive episiotomy practices among midwives
This study further investigates the relationship between the professional characteristics of midwives and their engagement in restrictive episiotomy practices.A significant finding is that midwives who attend home births, known for their training and familiarity with minimal intervention during childbirth, exhibit a particularly restrictive approach to episiotomy in these typically low-risk settings, as supported by the literature (Grünebaum et al., 2023).Another determinant of restrictive episiotomy practices is employment within a teaching hospital environment, where there exists an enhanced commitment to adhering to established guidelines.This commitment is due to the necessity for professionals to model best practices for their students, a correlation supported by additional research (Kozhimannil et al., 2017).
Furthermore, the duration since obtaining midwifery qualification emerged as a related factor.Given that teaching hospitals demonstrate a higher fidelity to restrictive episiotomy guidelines, it is plausible that midwives with more recent qualifications are inclined to maintain these practices over time.

| Strengths and limitations
One notable limitation of this study is the potential for subject selection bias.Our findings indicate that the majority of respondents were relatively young (56.1% aged between 26 and 35 years, and 56.8% obtained their midwifery degrees between 2015 and 2021).
This demographic skew could be attributed to their greater familiarity or engagement with the media channels used for distributing the questionnaire.While this might limit the generalizability of our results, it also offers valuable insights into emerging trends in childbirth care practices among the newer generation of midwives, which could be indicative of future directions in this field.

| Implications for clinical practice and research
Numerous clinical practice guidelines currently incorporate the latest evidence on optimal care strategies to reduce perineal trauma and mitigate its adverse effects.However, this study reveals that, while many midwives adhere to these recommendations, a significant number still employ practices that are not recommended, potentially due to gaps in training.
Therefore, it is crucial for health institutions and scientific societies to actively engage in the periodic updating of knowledge and skills of all professionals involved in childbirth care.This includes emphasizing the importance of applying care based on the best available evidence.
By doing so, these institutions can bridge the gap between recommended and actual practices, ensuring more consistent and effective care in the prevention and management of perineal trauma.

| CON CLUS IONS
This study highlights considerable variability in practices among Spanish midwives concerning the prevention and repair of perineal trauma.Notably, the practice of restrictive episiotomy (less than 10%) is predominantly observed among midwives who have undergone more recent training, those employed in teaching hospitals, and those attending home births.These findings underscore the need for enhanced training and increased awareness

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WHO) published recommendations for women's care (World Health Organization, 2018), as did the National Institute for Health and Care Excellence (NICE) (National Institute for Health and Care Excellence, 2014b).In Spain, the Ministry of Health, Social Policy and Equality published the CPG on Normal Childbirth in 2010 (Ministerio de Sanidad y Política Social, 2010).The aim of these guidelines and protocols is to reduce variability in care practices and to promote professional adherence to techniques or recommendations that mitigate perineal damage during the second stage of labour.

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total of 305 midwives participated, of whom 276 (90.5%) were women.Regarding the age of the midwives, 171 (56.1%) were between 26 and 35 years old, 296 (97%) worked at a public facility, 171 (56.8%) completed their residency training after 2015.Home births were attended by 35 (11.5%) of the midwives.Regarding their work centre, 263 (86.2%) worked in hospitals with resident training programmes, and were in hospitals handling 1000-3000 births annually.Detailed characteristics are presented in Table1.
Application of hot compresses.F I G U R E 3 Protection of the perineum with hands.F I G U R E 4 Active shoulders traction.TA B L E 2 Perineal protection.you use lubricant in the birth canal to reduce the risk of tearing?Use of episiotomy and perineal repair.
of warm compresses stands out as particularly widespread, with more than half of the midwives employing them regularly, following recommendations from institutions like the World Health Organization (WHO) (World Health Organization, 2018), the NICE (National Institute for Health and Care Excellence, 2014b), as well as the Spanish Ministry of Health (Ministerio de Sanidad y Política Social, 2010).When asked about the position of the hands during the second stage of birth, most of the midwives in our study chose to actively protect the perineum with one hand and control head deflection with the other one.Several studies have compared the efficacy of actively protecting the perineum with one hand while controlling Correspondingly, guidelines from societies like NICE recommend restrictive episiotomy practices (National Institute for Health and Care Excellence, 2014b).The WHO's 1996 objective suggested an episiotomy rate of close to 10% as reasonable (Technical Working Group, 1997), while other sources, including Hernández-Martínez et al. (2014), suggest that rates of around 25% might be safe, consistent with recommendations by the French National College of Gynaecologists and Obstetricians (Collègue National des Gynécologues et Obtétriciens, 2005).Rusav'y et al. (2005), in their report for the Collège National des